Smoking: Effect of Graphic Warnings on Cigarette Packages

The U.S. would have several million fewer smokers if graphic warning labels similar to those introduced in Canada nearly a decade ago were required on cigarette packs, according to researchers at the University of Illinois at Chicago and the University of Waterloo.

The Canadian labels led to a 2.9 to 4.7 percentage point drop in smoking rates - which would mean 5.3 to 8.6 million fewer smokers in the U.S. if the same result were obtained. The researchers used statistical methods to compare smoking rates in the U.S. and Canada for a nine-year period before and after the graphic warning labels were introduced in Canada. The price of cigarettes was factored into the analyses.

The study found the “regulatory impact analysis” used by the U.S. Food and Drug Administration to gauge the effectiveness of Canada’s graphic warning labels to be inaccurate. The FDA had estimated only a 0.088 percentage point reduction in smoking rates after graphic warning labels were mandated in Canada.

Jidong Huang, research specialist at UIC’s Institute for Health Research and Policy, said when he and his collaborators corrected the FDA’s methodological flaws and took into account the purchase prices paid by smokers, they found that graphic warning labels reduce cigarette-smoking prevalence at much higher rates. Graphic warning labels on cigarette packages have been implemented in more than 40 countries, but not in the U.S.

In 2009, the Family Smoking Prevention and Tobacco Control Act gave the FDA authority to regulate the manufacture, distribution and marketing of tobacco products, including requiring prominent warning labels for cigarettes and smokeless tobacco products. However, the tobacco industry challenged the FDA’s requirement for graphic warning labels, and a U.S. Court of Appeals ruled that the federal agency lacked evidence that graphic warning images would reduce the number of Americans who smoke. Studies had shown that such labels increase knowledge of the harmful effects of tobacco products, motivate smokers to attempt quitting, and decrease relapse rates among smokers who have quit, but not whether they reduce overall smoking rates.

The UIC and University of Waterloo researchers hope the new study will provide support for a revised FDA proposal to require graphic warnings. The FDA should “adopt a standard methodology in doing their regulatory impact analysis that is statistically sound and validated by social scientists,” said Huang. The “very rudimentary analysis” methods currently used by the FDA will cause problems in future proposals and regulations for new and emerging tobacco products, he said.

Geoffrey Fong, professor of psychology at the University of Waterloo, said the new study “adds to the strong and growing number of studies showing the powerful positive impact of graphic warnings on reducing smoking rates.”